Fillable CONFIDENTIAL STATE OF RHODE ISLAND STA TEMENT OF (State of Rhode Island)

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CONFIDENTIAL STATE OF RHODE ISLAND STA TEMENT OF (State of Rhode Island)

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CONFIDENTIAL
STATE OF
RHODE ISLAND
STA
TEMENT OF ASSETS, LIABILITIES, INCOME, AND EXPENSES
FAMILY COURT
, S.C Case Number
vs.
Name:
Telephone:
Address:
City/Town, State: Zip Code:
Employer: Occupation:
City/Town, State: Zip Code:
Yes No
Single Family
Yes No
Yes No
1. PERSONAL INFORMATION
Name of Insurance Provider:
2. DO YOU HAVE HEALTH INSURANCE?
DR-6/FINANCIAL STATEMENT
Number of Children Living With You:
Do you have a dental plan?
Do you have a vision plan?
Defendant's Attorney/Bar Number
Plaintiff
Defendant
Plaintiff's Attorney/Bar Number
Attorney's Telephone Number
Name of Insurance Provider:
Employer's Telephone Number:
Attorney's Telephone Number
A DR-6 shall be filed with Complaints for Divorce, Bed and Board Divorce, Miscellaneous Complaints, or Child Support Complaints. A
DR-6 shall be filed with Answers or Counterclaims or Modifications of Prior (Support) Orders.
Employer's Address:
If yes, single plan or family plan?
Name of Policy Holder:
Name of Policy Holder:
Name of Insurance Provider:
Name of Policy Holder:
DR-6
FC-5 (Revised November 2017)
1
CONFIDENTIAL
$ $
$ $
Weekly Bi-Weekly Monthly Annual
$
$
$
$
$
$
$
$ $ $ $
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Other: $
Other: $
Other: $
$ $ $ $
h) Dividends
i) Interest
j) Trusts
k) Annuities
d) Self-Employment (Attach a completed Schedule C
from your latest tax return)
e) Tips
b) Overtime
TOTAL LIABILITIES (From Page 8)
Total Monthly Expenses (From Page 5)
c) Part-Time Job
3. TOTAL ASSETS (From Page 7)
Total Monthly Gross Income (From Page 2)
l) Pensions
o) Disability
m) Retirement Funds
n) Social Security
p) Unemployment Insurance
y) Capital Gains
g) Bonuses
Subtotal:
f) Commissions
s) Child Support
a) Base Pay from Salary/Wages
z) Other Income (Specify below ):
Total Gross Income:
q) Worker's Compensation
r) Public Assistance (welfare, etc.)
v) Royalties and other rights
w) Contributions from household members
x) Income from S-Corps, C-Corps, LLCs, etc.
u) Rental from Income Producing Property (Attach a
completed Schedule A on Page 9)
t) Alimony
DR-6
FC-5 (Revised November 2017)
2
CONFIDENTIAL
Weekly Bi-Weekly Monthly Annual
$
$
$
$
$
$
Other:
$
$ $ $ $
$
$
$
$
$
$
$
$
Other:
$
$ $ $ $
$
$
$
$
$
$
Other:
$
$ $ $ $
$
$
$
$
$
$
Other:
$
$ $ $ $
5. EXPENSES (pages 3, 4, and 5)
1. Housing
Rent
Electricity
Mortgage Payment (Principle and Interest)
Property Tax
Condo Fee
Home Maintenance
Cable Television/Internet
Total Housing:
2. Utilities
Snow Removal/Lawn Care
Heating Oil
Wood/Coal/Pellets
Propane and Natural Gas
Telephone/Cell Telephone
Life
Water and Sewer
Trash Collection
Total Utilities:
3. Insurance
Homeowner
Renter
Vehicle
Health/Dental/Vision
Eye Care/Glasses/Contact Lenses
Prescription Drugs
Disability
Total Insurance:
4. Uninsured Health Care Expenses
Medical
Dental
Orthodontics
Therapy and Counseling
Total Uninsured Health Care Expenses:
DR-6
FC-5 (Revised November 2017)
3
CONFIDENTIAL
Weekly Bi-Weekly Monthly Annual
$
$
$
$
$
Other: $
Other: $
Other: $
$ $ $ $
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Other: $
$ $ $ $
$
$
$
$
$
$
$
Other: $
$ $ $ $
Other Vehicle Payments
Vehicle Maintenance
Expenses Continued to page 4
5. EXPENSES (continued)
5. Transportation
Primary Vehicle Payment
Dues and Memberships
Vacations
Tobacco/Alcohol Products
Clothing and Shoes
Hair Care
Toiletries and Cosmetics
Newspapers and Magazines
Education (personal)
Laundry and Dry Cleaning
Gifts
Gas and Oil
Registration and Tax
Total Transportation:
6. General and Personal Expenses
Groceries
Meals Eaten Out or Taken Out
Pet Food and Care
Church and Charities
Total Children's Expenses and Activities:
Entertainment and Recreation
Total General and Personal Expenses:
7. Children's Expenses and Activities
Children's Clothing
Diapers
Day Care
School Supplies
School Lunches
Tuition and Lessons
Sports and Camps
DR-6
FC-5 (Revised November 2017)
4
CONFIDENTIAL
Weekly Bi-Weekly Monthly Annual
$
$
$
$
$
$
Total Other Expenses: $ $ $ $
$
Number of
exemptions:
$
$
Number of
exemptions:
$
$
$
$
$
$
$
$
$
Other: $
$ $ $ $
$
$
$
$
Other: $
$ $ $ $
5. EXPENSES (continued)
8. Other Expenses (For example, ungarnished child support or alimony). Specify below.
Union Dues
Expenses Continued to page 5
9. Deductions from Paycheck
Federal Income Tax
State Income Tax
Social Security
Medicare
Local TDI
State Retirement
Savings
Total Financial:
Garnishments
401(k)
Other Retirement Plans
Loan Payments
Total Deductions from Paycheck:
10. Financial
IRA
Other Debts
DR-6
FC-5 (Revised November 2017)
5
CONFIDENTIAL
$ $ $ $
A. Real Estate
- Mortgage Balance:
Equity: $
- Mortgage Balance: $
Equity: $
- Mortgage Balance:
Equity: $
Total Real Estate Equity: $
Year Make Market Value Vehicle Loan Equity
Vehicle 1 $
Vehicle 2
Vehicle 3
Total: $
Type
Total: $
Total: $
Total: $
Death Benefit
Name
Value
Financial Institution or Plan Names:
Company Name
C. List IRA, Keough, Pension Profit Sharing, 401k, other Retirement or Financial Plans,
Value
D. Annuity Plan(s):
Primary Residence
Fair Market Value:
Fair Market Value:
Address: (street address, city, state, zip)
Real Estate:
Title Held in Name of:
B. Motor Vehicle:
Company
Cash Value
6. ASSETS
TOTAL EXPENSES:
Fair Market Value:
Address: (street address, city, state, zip)
Title Held in Name of:
Real Estate:
Address: (street address, city, state, zip)
Title Held in Name of:
DR-6
FC-5 (Revised November 2017)
6
CONFIDENTIAL
6. ASSETS (continued)
Total: $
Type
Total: $
Total: $
Total: $
Type
F.) Savings and Checking Accounts, Money Market Accounts, Certificates of Deposit -- Which are held individually, jointly, in
the name of another person for your benefit, or held by you for the benefit of your minor child(ren):
G.) List Mutual Funds, Stocks, Bonds, Savings Bonds, Brokerage Accounts:
Value
Type
Assets Continued to page 7
Value
H.) Financial Claims or Settlements from Any Source:
Institutions
Value
J.) Additional Assets: (Ownership Interest in Corporation, LLC, Life Estate)
Name
Value
I.) Deferred Compensation:
Description
Description
Value
DR-6
FC-5 (Revised November 2017)
7
CONFIDENTIAL
Total: $
TOTAL ASSETS: $
7. LIABILITIES (For additional liabilities attach separate form)
Creditor Nature of Debt Date Incurred Amount Due Monthly Payment
$ $
$
Date Signature
NOTARY CERTIFICATION
Notary Signature:
My Commission Expires:
FORM OF IDENTIFICATION:
Driver's License/State: __________ License Number
State of RI Identification
Passport
Total Assets Minus Total Liabilities:
I certify under the pains and penalties of perjury, the information stated on the DR-6, my financial statement and the
attached schedules, if any, is complete, true and accurate.
On this ________________ day of _____________________, 20____, before me personally appeared
___________________________________; he/she is personally known to me and/or he/she proved his/her identity
through satisfactory evidence of identification; he/she executed and acknowledged said instrument to be his/her free act
and deed.
TOTAL LIABILITIES:
DR-6
FC-5 (Revised November 2017)
8
CONFIDENTIAL
Birth Certificate
Other ID: _________________________
SCHEDULE A
Gross Annual Rent Received:
Property Address:
Annual Rental Expenses:
Advertising:
Motor Vehicle and Travel:
Insurance:
Cleaning and Maintenance:
Commissions:
Interest on Mortgage to Banks:
Other Interest (Specify ):
:
:
Legal and Professional Services:
Repairs:
Supplies:
Taxes:
Utilities:
Wages:
Other Expenses:
:
:
Total Annual Rental Expenses: $
Total Net Annual Rental Income: $
RENT FROM INCOME PRODUCING PROPERTY
DR-6
FC-5 (Revised November 2017)
9
CONFIDENTIAL
Total Net Monthly Rental Income: $
DR-6
FC-5 (Revised June 2020)
10
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CONFIDENTIAL STATE OF RHODE ISLAND STA TEMENT OF (State of Rhode Island)

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